Trainee Fellowship, USA - Paul Thiruchelvam

I am extremely grateful to the Association for awarding me a trainee fellowship. This provided funding for me to visit the “3Ms” - MD Anderson Cancer Center, Mayo clinic and Memorial Sloan Kettering for 5 weeks in 2015.

These represent the three premier cancer institutions in the United States, and would provide me with a flavour of breast cancer care in the United States.

The first leg of my fellowship took me to the MD Anderson (named after Monroe Dunaway Anderson a banker and cotton trader from Jackson, Tennessee) and ranked #1 for cancer care in the annual "Best Hospitals" survey. It was created in 1941 as the Texas State Cancer Hospital and renamed in 1942, providing care for 127,000 patients a year and employing more than 20,000 staff. The Texas Medical Center, which houses the MD Anderson is an enormous complex comprising 21 hospitals, 4 medical schools and seven nursing schools over an area of 1.8 square miles.

Houstonians are fiercely proud of the MD Anderson which is apparent at the airport as enormous banners advertising the hospital greet you, including those with the hospital motto, 'Making Cancer History'.

My sponsor was Professor Alastair Thompson, who had recently moved from Dundee to join his wife, Dr Stacey Moulder, an oncologist who also works at the MD Anderson. They provided me with an overview of American healthcare and the pros and cons of working at such a large institution. A fellow trainee, Miss Beatrix Elsberger (Ninewells Hospital, Dundee) was also visiting Houston at the same time and Alastair had arranged a very extensive program of events for both of us including regular theatre sessions, research meetings and clinics with many of the 15 surgeons in a department who treat more than 3000 cancers per year.

I was able to join Professor Thompson at radiotherapy planning meetings where the surgery of the individual patients was discussed with the clinical oncologists facilitating more accurate delivery of RT. Speaking to the clinical oncologists, they felt that they were able to better plan their radiotherapy with a surgeon present in these meetings and it made me very aware of the extent of clip distribution that occurs during a therapeutic mammoplasty. I was privileged to tour the MD Anderson Proton Therapy Center, which first opened in 2006 and is one of ten such units in the United States. Dr Eric Strom showed me the $200million center, which is located off campus (as it was funded by a group of private investors and the MD Anderson is a not-for-profit organisation). Proton therapy is a form of external beam radiotherapy that permits high doses of radiation to the tumour area while preventing radiation from affecting surrounding healthy tissues and nearby organs such as the lungs and the heart. The suite’s 3 gantries run from 6am to midnight generating protons from one synchrotron particle accelerator. Each gantry has an internal diameter of 5 m and a weight of 200 tonnes and thus, the footprint of the unit is vast. Eric was quick to admit that the published experience to date with protons for accelerated partial breast irradiation (ABPI) has been limited and the results mixed, but they continue to recruit patients with small breast cancers that have not had a significant parenchymal rearrangement (all other patients have external beam whole breast radiotherapy with photons). Construction is currently underway for two proton beam therapy cancer centres at University College Hospital, London and The Christie in Manchester at a cost of £250 million. It certainly was a glimpse into the future.

I was also able to see how a successful radioiodine seed localisation program had been set up as a replacement for wire localisations in patients with impalpable cancers and their utility in targeted axillary dissection following neoadjuvant chemotherapy. This has transformed the pre-operative planning of patients with impalpable lesions and as a way of restaging the axilla in node positive patients. Dr Abigail Caudle advised the technique did have downsides including potential for losing seeds and the inability to use suction during the procedure However, their initial experience had been very positive with a positive margin rate in T1-T2 tumours of 8% now being reported.

The low-positive margin rate could be explained by intraoperative pathological assessment of specimens. A team of pathologists are employed to cover the 6 breast theatre lists running every day, providing almost real time assessment of margins to the surgeon. All specimens are evaluated by a consultant histopathologist and radiologist and a decision on a margin reported within 20 minutes! With UK re-excision rates between 20-30%, perhaps employing a histopathologist to give real-time information on margins may be cost effective! Whilst, clearly this is not the future and the answer lies in the use of technologies such as the marginprobe, iknife and molecular fluorescence guided surgery.

During a weekly research meeting I was able to present some preliminary data from the ongoing UK pre-operative radiotherapy pilot study currently undergoing at Imperial/Royal Marsden and Professor Henry Kuerer shared with me his protocol for his feasibility pilot study for “Identification of Breast Cancer Patients for Potential Avoidance of Surgery” (Clinicaltrials.gov NCT02455791) – yes, paving the way for no surgery! Patients with an exceptional radiological response to chemotherapy, as assessed using functional imaging, and assuming pCR (i.e. HER2+ and triple negative breast cancers) will be eligible and offered image guided fine needle aspiration and vacuum-assisted biopsies. The accuracy of this intervention will be documented with routine surgery and complete pathologic evaluation. Similar trials are ongoing in the Netherlands and the UK (NOSTRA – Feasibility. A Prospective Non Randomised Multicentre Feasibility Study to Assess if Patients with Residual Cancer Following Dual-Targeted Neoadjuvant Chemotherapy Treatment for HER2 Positive, ER Negative Early Breast Cancer can be Identified by Multiple Image Guided Tumour Bed Biopsies – Adele Francis, Birmingham).

As my colleague, Daniel Leff, has highlighted in an earlier ABS report, survivorship is actively celebrated, with statements from cancer survivors found everywhere in the complex. Whilst sharing personal experiences publicly is very American (and perhaps not particularly British), for many of the staff it reminded them of the reason why they work so hard and I found it quite inspirational. All staff wore lanyards with “I am MD Anderson” – giving them a real sense of shared purpose.

Away from the hospital, there is lots to see in southern Texas, and a drive to the coast gave me an insight into how Texans spend time by the sea. A beach full of pick-up trucks parked in a line all kitted out with BBQs by the waters-edge is standard – only in America! Both myself and Beatrix were made to feel part of the team and actively encouraged to provide a “UK perspective” on a regular basis. At the start of our placement Professor Thompson and his wife Stacey invited myself, Beatrix and the new breast fellows to his house for a welcome BBQ, and at the end of our stay Professor Thompson and Dr Kelly Hunt made the effort to take us both out for dinner.

The second leg of my fellowship took me to Mayo clinic in Rochester Minnesota. Mayo clinic was founded by William Worrall Mayo (born in Manchester, UK), his two sons William James Mayo and Charles Horace Mayo, and Henry Stanley Plummer (Plummer-Vinson syndrome and Plummers nails) as a Group Practice in 1892 at the Saint Marys Hospital. The hospital is now a huge non-profit organization employing more than 4,500 physicians and scientists and 57,000 allied health professionals. My sponsor was Dr Judy Boughey, a UK trained doctor (having attended Cambridge), who completed her residency and fellowship training in the US (South Carolina and MD Anderson). She has been a consultant at the Mayo since 2006 and is chair of surgical research having led the multicentre national study (ACOSOG-Z1071), a successor trial (Alliance A11202) and the Breast Cancer Genome-Guided Therapy (BEAUTY) study.

The approach to breast cancer care at Mayo is more in keeping with a UK model with all patients discussed in a weekly MDT meeting, as opposed to the practice at other centres where the ‘MDT’ takes place between one oncologist and the surgeon in clinic. During my time at Mayo, I observed Dr Steven Jacobson (plastic surgeon) perform a bilateral pre-pectoral expander reconstruction using 2 x alloderm ADMs (no expense spared) to hold the implant. Dr Jacobson has been performing this technique for several years and now very rarely places the implant under the muscle. He advised me that this approach prevents animation deformity and results in much less morbidity for the patients. In most cases a 2-staged procedure is performed, with lipofilling undertaken to correct the possible contour deformity at the upper-pole of the reconstruction at the time the expander is exchanged for an implant. His short- and medium-term results are impressive and the position of the implant durable. Dr Jacobson used a SPY-Elite to assess the vascularity of the skin flaps following mastectomy for every case and partially inflated the expander with “air” not saline for the first 2 weeks following reconstruction. This reduces the weight and hence pressure on the skin flaps, and is exchanged for saline at first clinic expansion. Ingenious – definitely something I have taken home with me and incorporated into my practice.

At Mayo, I had the pleasure of meeting Dr Deborah Rhodes, a breast physician with an interest in Molecular Breast Imaging (MBI). This imaging modality is used as a supplement to mammography in women with dense breasts. In the US, Connecticut was the first state to pass a law requiring physicians to offer supplemental whole-breast ultrasonography to women with dense breasts. Since then, the number of breast-density laws in the United States has grown rapidly: as of January 2015, a total of 21 states had adopted such legislation. Dr Rhodes explained how MBI could be used to significantly improve detection rates of mammographically occult cancers in women dense breasts. Prospective trials in the UK are due to start recruiting patients in both symptomatic and screening groups.

The final part of my fellowship took me to Memorial Sloan Kettering, New York. Memorial was founded in 1884 as the New York Cancer Hospital and is one of the oldest cancer centres in the United States. My time at Memorial was spent principally with Dr Joseph Dayan (Plastic Surgery) who has developed a breast-cancer-related-lymphoedema (BCRL) programme at Memorial and Dr Andrea Pusic, who has pioneered patient-reported outcome measures in breast surgery – the BREAST-Q.

Dr Dayan has a real passion for improving the quality of life in women with lymphoedema following breast cancer. In his own words, he said that he could have set up a boutique breast reconstruction clinic in New York but wanted to make a real difference, so spent 2 years undertaking a “super-microsurgery” fellowship in Taiwan. Rather than use lymphovenous anastomosis (LVAs) which is the most commonly used technique for treating BCRL in the UK, Dr Dayan uses vascularised lymph node transfer (vLNT). With this technique, a cluster of lymph nodes are harvested from a donor-site such as the groin, supraclavicular region or the contralateral axilla. Reverse mapping is used to prevent donor site morbidity (i.e. lymphoedema from the donor site) and the nodes transferred to the most distal lymphatic blockage in the affected limb (as determined using pre-operative ICG). Thus, far Dr Dayan has performed more than 100 vLNTs with zero-donor site morbidity. He is very careful about patient selection and his preoperative work-up exhaustive – using pre-operative photography, perometry, bio-impedance, MRI and lymphoscintigraphy. He explained the difference between “early” and “late” lymphoedema and the importance of detecting the difference between fatty and non-fatty lymphoedema. I was fortunate enough to see Dr Dayan operate and it was great to see a team of surgeons work so well together.

Finally, I saw how the BREAST-Q, which was developed at Memorial Sloan Kettering by Andrea Pusic, provides objective data on surgical procedures based on several quality-of-life and satisfaction domains. This is fully integrated into practice and gives clinicians and researchers a simple and accurate way to analyse their data and helps patients decide what breast surgery treatment option is right for their individual needs. Breast surgeons may soon have to present their surgical outcomes and objective measures such as the BREAST-Q will capture information from their patients. Patient data at Memorial is prospectively collected on central databases which drives a significant proportion of the research at the hospital. The physicians simply ask a question, such as “10 year survival outcome data of women with breast cancer <40 years of age” and the data is then electronically collected, analysed and presented back to them to them! If only it were so easy back home.

This fellowship has not only allowed me to see first-hand how breast cancer is managed in a different medical system other than the NHS, but has enabled me to develop life-long friendships and provide opportunities for collaboration in the future. I feel very fortunate to have visited these unique institutions and would like to take this opportunity to thank both my host sponsors and the Association. I will leave the final words to William Mayo, whose sign above the desk in his office simply read “There’s No Fun Like Work”.